Position Overview:

Develops and monitors care plans for home and community-based individuals that are ethical and person-centered while ensuring consistent provision of quality services in keeping with individual goals and objectives, agency philosophy, policies and program requirements, as well as requirements of IFSSA, the accrediting body, and other regulatory agencies.

Essential Functions:

Advocacy & Service Coordination

• Completes all tasks with a sense of urgency, effectively prioritizes to ensure timely and effective customer service.
• Advocates for the individual by educating, encouraging, and empowering them to prolong their independence, recognizing situations that warrant additional coordination and support.
• Completes person-centered assessments and develops person-centered care plans based on the individual’s needs, strengths, and preferences. Identifies options for service delivery including type of service(s), program eligibility and payment source(s) in keeping with agency philosophy, program requirements, and individual independence.
• Ensures services authorized in plan of care are in place and addressing individual’s functional and environmental needs. Contacts each individual within required time frame to follow up on service start date. Continually monitors, reevaluates situations, addresses concerns, and updates care plans, as needed.
• To meet temporary and/or ongoing needs that cannot be met through other formal and informal sources, develops creative solutions including recruitment of volunteers. Ensures continued identification of new resources to assist individuals and their caregivers.
• Handles individual or provider concerns or requests regarding services, billing, or other needs.
• Maintains necessary contact with care team to ensure a person-centered and all-encompassing approach to the individuals plan of care.
• Coordinates with Adult Protective Services, Guardianship Case Manager(s), and formal and informal supports when individual situations warrant.
• Refers individuals for Legal Aid, Ombudsman services, Senior Nutrition Activity Centers, housing, public transportation, community resources, guardianship services, and other resources as necessary.
• Appropriately identifies cases for case conferencing and confers with supervisor as needed.
• Participates actively in the staff meetings and case conferences.

Productivity

•  Achieves established productivity standards in the areas of:
  • 90% compliance with due dates including, but not limited to quarterlies, semi-annuals, and annuals
  • 90% compliance with all pay point due dates
  • 60% of quality assurance surveys must be positive
  • 100% of time is case noted
• Performs within expectations in the area of:
  • Caseload per home care manager
  • Billable unit percentage per month (80%)
  • Average care plan costs per home care manager
  • Compliance of care plans with eligibility, funding logic, and cost share level
• Consistently and effectively utilizes case coordinator assistance and delegates an appropriate number of tasks.

Compliance

• Distributes the following to individuals:
  • Appropriate contact information
  • Instruction on how to request an appeal
  • Guidance on how to choose a provider
  • Agreed upon care plan
  • State of Indiana potential provider list to waiver individuals
• Respects the individuals’ right to choose or change their service provider and/or case manager.
• Initiates timely tracking, intervention, follow-up and resolution of identified problems, complaints, critical or crisis issues, including filing incident reports and recording all individual activity in state approved software.
• Accurately assesses Level of Care using the state InterRAI form and Form 11 and provides sufficient justification for identified needs, documenting in accordance with state and agency protocol.
• Completes all requirements of Initial, Quarterly, Semi-Annual, and Annual Assessments; makes additional home visits, as needed.
• Completes Person Centered Goal Setting and follow up according to procedure.
• Completes Caregiver assessments, Healthy Ideas screening, and Quality of Life surveys, within established timeframe and follow up according to procedure.
• Records all individual related activity in case record within seven days and according to protocol; maintains up to date individual files; uses assigned database software program to enter all individual data into system; logs time spent on individual activity in database software.
• Assigns tasks via CaMSS and monitors to ensure timely completion.

Administrative/General

• Maintains the highest professional and ethical standards.
• Respects the individual’s right to privacy as stated in LifeTime’s Public Notice of Confidentiality/Privacy Practices.
• Educates individuals, caregivers, and the community regarding the importance of donations.
• Consistently and effectively utilizes position procedures; recommends changes when necessary.
• Keeps abreast of all home and community care rules and regulations. Attends trainings as required and keeps abreast of issues and information necessary to perform work duties.
• Adheres to agency policies and procedures.
• Understands, supports, and models the agency’s Mission-based Values.
• Participates as needed in fundraising for the agency and represents the agency in the community.
• Engages in other related activities or special projects as required or assigned.

The essential functions identified here are a representation of those duties required of this position and in no way are intended to be a complete list.

Performance Requirements:

Knowledge, Skills, Abilities, & Mental Demand: Clerical and computer skills, including ability to use Microsoft Office Suite; written and verbal communication skills; listening skills; interpersonal skills; customer service skills; reasoning and problem-solving skills; ability to work with minimum supervision; public speaking and presentation skills; networking skills; telephone skills; ability to perform multiple concurrent tasks in an organized manner.

Physical Effort: Sedentary Work: Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently; ability to climb stairs and independently access all customer homes.

Working Conditions: Office environment, regular travel in a personal vehicle; customer homes; possible exposure to bodily fluids; customer contact; occasional inclement weather.

Education, Experience and Training: A registered nurse—or—A Bachelor’s degree in Social Work, Psychology, Counseling, Gerontology, Nursing or Health & Human Services—or—A Bachelor’s degree in any field with a minimum of two years full-time, direct service experience with the elderly or disabled (this experience includes assessment, care plan development, and monitoring)—or—A Master’s degree in Social Work, Psychology, Counseling, Gerontology, Nursing or Health & Human Services may substitute for the required minimum of two full time direct services experience—or—An Associate’s degree in Nursing—or—An Associate’s degree in any field with a minimum of four year full-time, direct service experience with the elderly or disabled (this experience includes assessment, care plan development, and monitoring). Must receive Case Management Certification from the state upon hire. Once certified, must attend 20 hours of approved training each year; must have a valid driver’s license.